South American survey finds rectal microbicide formulated as a douche acceptable

A qualitative study of 140 men who have sex with men (MSM) and transgender women (TGW) in three cities in Peru and Ecuador has found that most thought that a rectal microbicide formulated as a douche, rather than as a gel or lubricant, might offer additional safety or efficacy.

However, it also found that participants doubted the practicality of such a formulation for use in sex away from home. The researchers also comment that interviewees who regard douching as hazardous would be unlikely to change their minds and adopt a microbicide douche.

The researchers also discovered in the course of their research that some participants were already using a variety of homemade douching preparations before anal sex, some of them potentially hazardous or downright toxic. They comment that regardless of the desirability of a rectal microbicide douche, "education on rectal douching practices is needed now".

This study follows on from several other studies of rectal douching in MSM and TGW. A study in the USA (Carballo-Diéguez) found that 53% of HIV-negative MSM there douched in preparation for anal sex. A global survey (Stahlman) by International Rectal Microbicide Advocates (IRMA), presented at the Microbicides 2012 Conference in Sydney last year, found that 63% of the people who answered the survey (mainly MSM) douched rectally before receiving anal sex, with only 25% using commercial enema products and most using shower hoses and homemade kits made from bottles. Douching was more common in people with HIV, and people who douched averaged five partners a month compared with two among those who did not douche, suggesting that a rectal douche focused on people at high risk of HIV might be effective.

A previous study from three cities in Peru (Kinsler) found that only 27% of MSM/TGW douched rectally before receptive anal sex but that 80% said they would use a microbicide douche if it had efficacy against HIV infection. Participants who already douched were more than twice as likely to say they would use a rectal microbicide douche and those from the capital, Lima, were twice as likely to say they would use a microbicide douche as those from the other two cities, which were the smaller and more remote jungle cities of Iquitos and Pucallpa.

The current survey interviewed 104 participants in focus groups and 36 in indepth interviews, with approximately equal numbers coming from Lima and Iquitos in Peru and Guayaquil in Ecuador. Participants were in the main mixed-race, aged under 30 (only 10-12% were 30 or older in Iquitos and Guayaquil, 38% in Lima), had at least high-school education and were employed.

Participants thought that a douche microbicide would be useful because it would "kill two birds with one stone, because I would take care of hygiene and protect myself at the same time".

People thought a rectal douche might be more protective than a lubricant-type gel "because this is going to have more effect; it is going to go deeper into your body".

Some people found, however, that douching increased the discomfort of sex because it removed natural mucus: "You end up really dry, you don't have anything from your body to lubricate, and in the end your partner is going to be uncomfortable".

Others doubted that a douche microbicide would be practical in many situations: "sometimes there's no time to put on a condom, much less apply an enema."..."Wouldn't you have to carry a huge tube around? You can put a condom and lube in your pocket".

While some participants doubted that a douche microbicide would be protective as they had heard that douching actually increased the risk of HIV: "You use enemas forcefully because that does the cleaning, don't you? And that is extemely harmful to our health".

The researchers conclude that a douche microbicide might well find a market among people who would see it as potentially more efficacious than a gel or lube, but that concerns had emerged about its practicality in away-from-home situations. They also comment that the use of a rectal microbicide douche would likely "be confined to those who already practise the procedure."

The researchers also discovered, serendipitously, that many participants were already using a variety of homemade douches that could increase the risk of acquiring HIV and which in some cases were hazardous to health.

The most popular single douche was simply to use water from a shower hose, but participants also used a variety of liquids including soap and water, detergent or shampoo; lemon juice or vinegar; camphor; a mixture of soap, bleach and isopropyl (rubbing) alcohol; and drinking alcohol in the form of vodka or other spirits. They used plastic soda or hair-dye bottles as applicators.

The researchers comment that this finding shows that there needs to be more research into how MSM and TGW use douches and why: are alcohol douches, for instance, aimed at cleanliness or intoxication? Which partner, insertive or receptive, instigates douching?

They also comment that "regardless of rectal microbicide development, there appears to be an immediate need for HIV prevention messages to include information on safer rectal douching practices, specifically with regard to 'homemade' douching liquids".